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resident:stephanie_malliaris [2021/02/03 00:49] – jonathanresident:stephanie_malliaris [2021/08/19 13:13] (current) – taylor
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 Integrated Plastic Surgery at Weill Cornell - 2007-2014\\ Integrated Plastic Surgery at Weill Cornell - 2007-2014\\
 Fellowship in Hand at Hospital for Special Surgery (HSS) - 2015\\ Fellowship in Hand at Hospital for Special Surgery (HSS) - 2015\\
-Denver Health - 2015 - \\+Denver Health - 2015 - Forever \\
  
 [[https://drive.google.com/drive/folders/13OAdYirQWQssfwj0gS8XHlykjXFoTq-a?usp=sharing|Dr. Malliaris Publications]] [[https://drive.google.com/drive/folders/13OAdYirQWQssfwj0gS8XHlykjXFoTq-a?usp=sharing|Dr. Malliaris Publications]]
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 \\ \\
 ===== Hand ===== ===== Hand =====
 +
 +==== Flexor Tendon Repair (Zones 1 and 2) ====
 +
 +<WRAP group>
 +<WRAP half column>
 +POSTOPERATIVE DIAGNOSES:
 +1.  Crush injury to hand.
 +2.  Complete transection of the flexor digitorum profundus, zone 2, right long 
 +finger.
 +3.  One slip, complete transection of flexor digitorum superficialis, zone 2 to 
 +right long finger.
 +4.  A 90% transection FDP to index finger, zone 1.
 +5.  Laceration to ring finger and small finger volar aspect.
 +
 +PROCEDURES:
 +1.  Washout and excisional debridement of crush wound to right hand index finger, 
 +long, ring, and small fingers.
 +2.  Repair of FDP tendon, right long finger, zone 2.
 +3.  Repair of FDP tendon in zone 1, right index finger.
 +4.  Closure of simple laceration, right ring finger and small finger.
 + 
 +
 +DESCRIPTION OF PROCEDURE:  The patient was brought to the operating room.  He 
 +remained on the stretcher.  The right upper extremity was put on a hand table.  Bony
 +prominences were padded.  SCD boots were placed.  Preoperative antibiotics were 
 +given.  General anesthesia was administered.  The right upper extremity was prepped 
 +and draped in the usual sterile fashion with a tourniquet on the upper arm.
 +
 +Surgical pause was performed in accordance with hospital regulations.  The right 
 +upper extremity was elevated and exsanguinated using Esmarch bandage and the 
 +tourniquet was inflated to 250 mmHg.  We used a Tupper retractor and removed all the
 +prior placed sutures and investigated the wounds.  We started with the long finger. 
 +A Bruner incision was used to extend the wound proximally and distally, and it was 
 +noted that the neurovascular bundles were grossly intact, but there was complete 
 +disruption of the FDP tendon in zone 2, as well as one of the slips of the FDS 
 +tendons.  The A3 pulley and part of the A4 were also injured and not in continuity. 
 +The tendon injury was actually more distal, and as such, we opened Bruner wires 
 +distally to the distal phalanx and located the distal end of the tendon through the 
 +A4-A5 area.  The remainder of the A4 pulley needed to be opened.  The proximal end 
 +of the tendon was brought through the A2 and A3 area pulleys.  We irrigated this 
 +with copious saline and used a 3-0 Supramid to do a modified Kessler repair of the 
 +FDP tendon.  This then had an epitendinous 6-0 Prolene placed circumferentially 
 +around the tendon.  The finger was ranged and it did achieve what appeared to be 
 +full flexion.  The other slip of the FDS tendon was trimmed and the radial slip 
 +remained intact and had not been injured in the accident.  The area was irrigated 
 +and the Bruner flaps were placed over the tendon.
 +
 +We turned our attention to the index finger.  The laceration was irrigated and 
 +excisional debridement was performed of skin and subcutaneous tissue.  This was done
 +with scissors, and the area was 3 x 2 cm.  We explored the wound and found a 90% 
 +lacerated FDP tendon in zone 1.  As there was not much tendon distally, we elected 
 +to repair this with a suture anchor.  The area was cleaned off and a mini Mitek with
 +2-0 suture was drilled and placed into the volar aspect of the distal phalanx.  We 
 +then used the 2-0 suture to repair the tendon to the distal phalanx, and 6-0 Prolene
 +was then used for further strength repair at the tendon laceration site.  This was 
 +then irrigated.
 +
 +We then did the excisional debridement of the skin and subcutaneous tissue of the 
 +long finger.  The nonviable edges were trimmed.  This was approximately 3 x 0.5 cm 
 +area.  The debridement was skin and subcutaneous tissue and it was done with an 
 +Adson.
 +
 +We then turned our attention to the ring and small fingers.  The 2 other lacerations
 +were explored, tendons were intact in the ring finger and in the small finger.  It 
 +did not extend into the flexor sheath either.  Excisional debridements were 
 +performed, 1 cm x 0.5 cm for of these lacerations.
 +
 +The Irrisept wound irrigation system was used, 500 mL to irrigate all four of the 
 +lacerations.  We then released the tourniquet and normal perfusion returned to the 
 +hand and fingers.  Hemostasis was ensured and then the incisions were closed with 
 +interrupted 4-0 nylon sutures.
 +
 +A dorsal blocking splint was placed after bacitracin, Adaptic, and sterile Webril.
 +
 +</WRAP>
 +
 +<WRAP half column>
 +Irrigation with Irrisept 500mL
 +
 +Tourniquet: Sterile; arm
 +
 +Drain: None
 +
 +Sutures: 
 +- Skin: 4-0 nylon
 +- FDP zone 2: modified Kessler with 3-0 Supramid, epitendinous with 6-0 Prolene
 +- FDP zone 1: mini Mitek with 2-0 suture was drilled and placed into volar aspect of distal phalanx, 2-0 suture to repair tendon to distal phalanx, 6-0 prolene to reinforce
 +
 +Dressing: Bacitracin, Adaptic, Webril, dorsal blocking splint\\
 +
 +Anatomy: FDP/FDS insertions, zones of injury, Camper's chiasm, neurovascular bundles\\
 +
 +Post-operative care: Elevate LUE, splint care, f/u 1-2 weeks, OT referral for flexor rehab protocol\\
 +
 +Attending Pearls (Learning points/Pimp Questions): N/A\\
 +
 +
 +</WRAP>
 +</WRAP>
  
 ==== Metacarpal Nail ==== ==== Metacarpal Nail ====
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 </WRAP> </WRAP>
 </WRAP> </WRAP>
 +
 +
 ==== Dequervain's Release ==== ==== Dequervain's Release ====
  
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 </WRAP> </WRAP>
  
- +==== Wedge Osteotomy of Metacarpal with ORIF ====
-==== ORIF Scaphoid, Volar Approach ====+
  
 <WRAP group> <WRAP group>
 <WRAP half column> <WRAP half column>
 +Procedure:\\
 +1. Wedge Osteotomy of Metacarpal with Open Reduction and Internal Fixation
 +\\
 +OPERATIVE APPROACH: The patient was identified in the preoperative care area where written consent was reviewed with the patients. The surgical site was marked with a marker. All of her questions were answered and concerns were addressed. The patient was brought back to the operating room by the anesthesia staff. All pressure points were well padded. A surgical time-out was performed per protocol, and 2 grams of Ancef were administered prior to the start of the procedure. General anesthesia was then obtained. A nonsterile tourniquet was placed to the appropriate extremity, which was then prepped and draped in a standard sterile fashion.
  
-Operative Report +We began by making a curvilinear incision on the radial aspect of the second metacarpal bony prominence, extending the incision proximally and distally to the base and head of the metacarpal, respectively. A tenotomy was used to dissected down through the subcutaneous tissue to the periosteum. Bipolar electrocautery was used to achieve hemostasis. Significant scar tissue was encountered around the malunion segment of the metacarpal.  Once there was adequate clearance of the overlying scar tissue, a 15 blade was used to sharply incise the periosteum. A freer was used to elevate periosteal flaps from the metacarpal shaft in the radial and ulnar directions, taking care to leave it attached at the most volar aspect of the bone. 
-1.ORIF left scaphoid nonunion with autograft harvested from volar distal radius cortex and headless cannulated 3.0mm Synthes screw+ 
 +Fluoroscopic imaging was used to visualize the second metacarpal and design the wedge osteotomy.  It was determined that an open wedge osteotomy would be most adequate to correct the dorsal osseous hump and align the metacarpal in a more anatomic position. Using an oscillating saw, two cuts were made to remove a wedge of bone. A rongeur was used to smooth the edges of the proximal and distal aspects of the cut metacarpal. Next a 1.5 mm plate was chosen, the metacarpal was reduced and fluoroscopic imaging was obtained to determine plate length and placement. A plate cuter was used to remove 4 drill holes from the plate and once we were satisfied with plate placement, we used a 0.45" K-Wire to place the proximal aspect of the plate.
  
-The patient was taken to the the operating room and secured with all bony prominences padded and following patient and procedure confirmation, anesthesia was started. The site was prepped and draped in usual sterile fashion. A pre-operative time-out was performed confirming site, laterality, patient and procedure to be performed. +Next we drilled a bicortical screw hole most proximal to the fracture site, placed a non-locking screw and confirmed plate placement with fluoroscopic imaging. These steps were repeated to place non-locking, bicortical screws at the most proximal screw hole distal to the osteotomy site and then again on the proximal aspect of the plate until 3 screws were placed at both the proximal and distal aspects of the osteotomy site for a total of 6 screws. The K-wire was removed and the final reduction was confirmed with fluoroscopic imaging. The wound was irrigated and hemostasis was achieved. 4-0 vicryl was used to approximate the subcutaneous tissue over the hardware in simple and interrupted figure of eight fashion. Finally, the skin was closed with simple interrupted stitches of 4-0 Nylon. 10 cc of 0.25% plain marcaine was injected into the operative site. The wound was dressed with xeroform,  4x4s and Webril. The right hand was placed into a well-padded volar splint with the hand in intrinsic plus. The patient was awakened from anesthesia and taken to PACU in stable condition.
-  +
-The arm was elevated and exsanguinated with an esmarch bandage and the tourniquet was inflated to 250 mmHg. +
-  +
-A volar approach to the wrist was made over the flexor carpi radialis with extension radially at the proximal wrist crease to avoid the palmar cutaneous nerve. The sheath overlying the flexor carpi radialis (FCR) was incised and the tendon was retracted ulnarly. The deep sheath was then incised and the tendons were retracted ulnarly. The joint capsule over the scaphoid was palpated and the position was confirmed by fluoroscopy. The joint capsule/ligaments were incised to reveal the scaphoid non-union. The fracture was opened with the freer and dental pick. Two 0.062 in k-wires were placed as joysticks in the proximal and distal scaphoid fragments. The nonunion was excised using the dental pick, rongeur and osteotome to fresh bone edges. +
-  +
-Attention was turned to the volar distal radius. Pronator quadratus was elevated. A 0.045" K wire was used to outline the graft in the volar cortex of the distal radius metaphysis. An osteotome was then used to excise the bone graft. Curette was then used to obtain more cancellous autograft. The graft was set aside. Cancellous bone chips were packed into the donor defect site and the pronator quadratus was repaired with 4-0 vicryl sutures. +
-  +
-Attention was returned to the scaphoid. Copious irrigation was performed to ensure that all edges of the proximal and distal aspect of the scaphoid as well as the cancellous portion of the scaphoid was completely debrided. The scaphoid was reduced using the k-wire joysticks, opening the humpback deformity. A guidewire for the 3.0mm Synthes cannulated headless screw was then placed from distal through the distal portion of the scaphoid, across the defect, into the proximal end. Fluoroscopy was used to confirm placement. A Kocher clamp was used to hold the joysticks in reduction. The guidwire was then withdrawn into the distal portion. The autograft from the distal radius was then packed into portion of the scaphoid nonunion, starting with the cancellous bone and then wedging in the corticocancellous graft. This was packed with a combination of a Freer as well as a tamp and gentle mallet.  +
-  +
-The guidewire was then advanced to the proximal scaphoid. Position of the guidewire was confirmed with fluoroscopy, and then a second de-rotational guidewire was placed. The guidewire was measured and was overdrilled and a 22mm 3.0mm Synthes headless compression screw was placed over the guidewire. This was carefully advanced and some compression was applied, taking care to not extrude the graft. Fluoroscopy confirmed good placement of the screw down the axis of the scaphoid and the guidewires and joy-stick k-wires removed.  +
-  +
-The joint capsule was closed with 3-0 vicryl sutures. At this point the tourniquet was let down and hemostasis was obtained. The incision was irrigated. The skin was closed with 4-0 nylon horizontal mattress sutures. The incision was dressed with xeroforom, 4x8 gauze and cast padding followed by a thumb spica splint.+
    
 </WRAP> </WRAP>
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 <WRAP half column> <WRAP half column>
  
-Photos\\+Operative Photos\\ 
 +{{ :resident:img_7965.jpg?200 |}} 
 +{{ :resident:img_7966.jpg?200 |}} 
 +{{ :resident:img_7967.jpg?200 |}} 
 +{{ :resident:img_7968.jpg?200 |}} 
 +\\ 
 +\\ 
 +Images include dissection down to the malunion, wedge design, more appropriate alignment after wedge resection and lastly plate fixation.\\ 
 +\\ 
 +Tourniquet: forearm 
 +Drain: none 
 +Sutures: 4-0 vicryl suture for periosteum/subq tissue. Skin with 4-0 nylon. 
 +Dressing: Xeroform, 4x4 gauze, Volar splint in intrinsic plus 
 +\\ 
 +Anatomy: Pertinent anatomy should be listed 
 +\\ 
 +Metacarpals are triangular in cross-section. The medial and lateral surfaces meet at the volar ridge, providing attachment to the interossei. These attachments together with the intermetacarpal ligaments proximally and distally help splint fractured bones, making functionally significant malunions of the ring and small metacarpals less common.\\ 
 +\\ 
 +Significant extra-articular malunions can cause crossing or scissoring of fingers, pain due to distortion of joints, disturbance of muscle/tendon balance, and reduction of grip strength.\\ 
 +\\ 
 +Extra-articular malunions associated with shortening can lead to an extension lag proportional to the degree of shortening.\\ 
 +\\ 
 +Intra-articular malunion with a significant step (0.5 mm) or gap (1 mm) may cause joint surface incongruity, synovitis, capsular loosening or stiffness, and, ultimately, painful posttraumatic arthrosis.\\
  
-Tourniquet: finger / forearm / arm\\ +Post-operative care:\\ 
-Drain: Type of drain and placement\\ +Volar splint in intrinsic plus positioning.\\ 
-Sutures: List all layers\\ +If adequate stability is obtained at the time of surgery, remove the postoperative splint 3 to 5 days after surgery and initiate protected motion.\\ 
-Dressing: What's preferred?\\+Initiate an early active and active-assisted ROM program.\\
  
-Anatomy: Pertinent anatomy should be listed\\+\\ 
 +Learning points/Pimp Questions: 
 +\\ 
 +Know the difference between an open vs closed wedge osteotomy. More commonly done in ortho in relation to the tibia, but concepts can be applied to other long bones as well.\\ 
 +\\ 
 +The wedge should be designed to help better align the long bone along its anatomical central axis.\\ 
 +\\ 
 +In the case of an intra-articular malunion, consider a salvage procedure rather than a repositioning osteotomy in the face of arthrosis.\\ 
 +\\ 
 +Accurate plate and screw placement is essential. A screw offset of 1 mm can cause as much as 10 degrees of rotation. 
 +\\ 
 +At least three screw holes are need proximal and distal to the osteotomy.\\ 
 +</WRAP> 
 +</WRAP>
  
-Post-operative care: - discharge to home with some pain medication; elevate; NWB L arm.\\ +==== Palmar Fasciectomy ====
-- F/U hand clinic 10-14 days for suture removal and thumb spica cast placement.\\ +
-- Cast x 6 weeks and then remove for re-evaluation.\\+
  
-Learning points/Pimp Questions:\\+<WRAP group> 
 +<WRAP half column>
  
 +INDICATION: This is a man who had previously been evaluated for Dupuytren's contracture of his left hand.  He had a pit that has gotten deeper with a proximal nodule turning into more of a Dupuytren's cord with some decreased extension of the RF MCP joint.  The patient complained of things getting caught in this on a regular basis and desired excision. We discussed the options for treatment of Dupuytrens and the risks and benefits of each
 +with the patient.  Patient elected for fasciectomy. These risks include pain, bleeding, scarring, infection, recurrence, possible need for wound care if unable to close the overlying skin, need for additional procedures.  The patient understood and wished to proceed.
 + 
 +
 +OPERATIVE APPROACH: 
 +The patient was identified in the preoperative holding area. Consent was confirmed, the appropriate side was marked as well as the boundaries of the cords. The primary cord was pre-tendinous proximal to the ring finger.  The patient was then taken to the operating suite and was left on the stretcher supine with all bony prominences padded. SCDs were placed. Appropriate perioperative antibiotics were given. A tourniquet was placed on his left arm.  Total tourniquet time was 75 minutes. An appropriate preoperative timeout was performed in which all parties were in agreement.The patient was then turned over to the anesthesia team for induction of anesthesia. The patient was then prepped and draped in the standard sterile fashion. 
 +
 +We began our procedure, marking a Brunner's incision that incorporated the pit for excision. We dissected down bluntly and easily identified the palmar cord just proximal to the ring finger. We dissected this out both ulnarly and radially until we had normal tissue and could isolate the cord. We then proceeded proximal and distal until we again encountered more normal fascia. We then dissected out the cord circumferentially, identifying both the radial and the ulnar neurovascular bundles. We also identified the flexor tendon to the ring finger underlying the cord. These structures were all carefully preserved.  We then excised the cord sharply. The RF was able to be extended to past 0 once the cord was cut. This was sent as a specimen for pathology. 
 +
 +We then established hemostasis using a bipolar electrocautery. We then, using iris scissors fully excised the pit, which did communicate with the cord. We then irrigated the wound and closed using interrupted 4-0 nylon sutures. We dressed the incision with Xeroform gauze, Webril, and then placed the patient in a resting volar splint.  The patient was turned over to the anesthesia team for awakening and taken to the PACU in good condition with plan for discharge home the same day.  All counts were correct at the end of the case.  The patient tolerated the procedure well.  
 + 
 </WRAP> </WRAP>
 +
 +<WRAP half column>
 +
 +Photos\\
 +{{:resident:img_7907.jpg?400|}}
 +{{:resident:img_7906.jpg?400|}}
 +
 +FINAL PATHOLOGY: Fibrovascular connect tissue and adipose tissue with focal increased myofibroblasts, consistent with palmar fibromatosis.
 +
 </WRAP> </WRAP>
 +</WRAP>
 +***
 +
 ==== A1 Trigger Finger Release ==== ==== A1 Trigger Finger Release ====
  
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 Photos\\ Photos\\
 +{{:resident:screen_shot_2021-08-02_at_3.56.00_pm.png?600|}}
 +
  
 Tourniquet: forearm\\ Tourniquet: forearm\\
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 ==== Enchondroma Curettage ==== ==== Enchondroma Curettage ====
  
 +<WRAP group>
 +<WRAP half column>
  
- +Operative Report:\\ 
- +1. Left index finger middle phalanx mass (findings consistent with enchondroma) curettage and bone grafting \\ 
-PROCEDURES PERFORMED:   +\\ 
-Left index finger middle phalanx mass (findings consistent with enchondroma) curettage and bone grafting +The patient was transported to Operating Room #4 and placed supine on the table with pressure points appropriately padded. A pre-anesthesia time-out was performed. Left upper arm tourniquet was placed. The patient was administered anesthesia without complication. Pre-operative antibiotic prophylaxis was administered. The surgical field was prepped and draped in the usual sterile fashion. A final time-out was performed. Anti-embolic compression devices were placed on bilateral lower extremities prior to induction. No Foley catheter was placed.
    
-DESCRIPTION OF PROCEDURE: The patient was transported to Operating Room #4 and placed supine on the table with pressure points appropriately padded. A pre-anesthesia time-out was performed. Left upper arm tourniquet was placed. The patient was administered anesthesia without complication. Pre-operative antibiotic prophylaxis was administered. The surgical field was prepped and draped in the usual sterile fashion. A final time-out was performed. Anti-embolic compression devices were placed on bilateral lower extremities prior to induction. No Foley catheter was placed. +A radial midlateral incision was planned over the middle phalanx. The left upper extremity was then exsanguinated with tourniquet at 250 mmHg. Incision was then made and meticulous dissection occurred until we reached the radial aspect of the periosteum overlying the middle phalanx. This was then probed with a freer until a soft spot was reached. Once this was identified, a longitudinal incision was then made with a beaver blade into the radial aspect of the middle phalanx. Once the cortex was penetrated, there was, what appeared to be cartilaginous material encountered. This was carefully curetted and a specimen was sent to pathology. While awaiting preliminary pathology, the remainder of the material was removed, within the confines of the middle phalanx cortex. This was performed in conjunction with review of the MRI as well as with intraoperative fluoroscopy, using a 25-gauge needle to mark the extent of the cavity within the cortex. Once all of the material was removed, this was sent to pathology, and copious irrigation was used to clean the cavity. Additional curettage was performed until the cortex was reached circumferentially. Pathology returned as what appeared to be cartilaginous material. Therefore, the cavity was packed with cancellous bone chips tightly and the area was again cleansed, and the skin was closed with 5-0 Nylon, simple interrupted sutures with good opposition and eversion. Local anesthetic was injected into the surgical site for a digital block. The skin was cleansed, and the wound was dressed with a strip of Xeroform gauze, then 4x4 gauze, and a well-padded radial gutter plaster splint with bias, with the wrist in neutral. 
-  +
-A radial midlateral incision was planned over the middle phalanx. The left upper extremity was then exsanguinated with tourniquet at 250 mmHg. Incision was then made and meticulous dissection occurred until we reached the radial aspect of the periosteum overlying the middle phalanx. This was then probed with a freer until a soft spot was reached. Once this was identified, a longitudinal incision was then made with a 69 beaver blade into the radial aspect of the middle phalanx. Once the cortex was penetrated, there was, what appeared to be cartilaginous material encountered. This was carefully curetted and a specimen was sent to pathology. While awaiting preliminary pathology, the remainder of the material was removed, within the confines of the middle phalanx cortex. This was performed in conjunction with review of the MRI as well as with intraoperative fluoroscopy, using a 25-gauge needle to mark the extent of the cavity within the cortex. Once all of the material was removed, this was sent to pathology, and copious irrigation was used to clean the cavity. Additional curettage was performed until the cortex was reached circumferentially. Pathology returned as what appeared to be cartilaginous material. Therefore, the cavity was packed with cancellous bone chips tightly and the area was again cleansed, and the skin was closed with 5-0 Nylon, simple interrupted sutures with good opposition and eversion. Local anesthetic was injected into the surgical site for a digital block. The skin was cleansed, and the wound was dressed with a strip of Xeroform gauze, then 4x4 gauze, and a well-padded radial gutter plaster splint with bias, with the wrist in neutral. +
    
 The tourniquet was released at the end of the case and all digits had good capillary refill afterwards, brisk, 2-3 seconds, and were warm and pink. The tourniquet was released at the end of the case and all digits had good capillary refill afterwards, brisk, 2-3 seconds, and were warm and pink.
    
 The patient was awoken from anesthesia and transferred to the PACU in good condition with no apparent complications. The patient was awoken from anesthesia and transferred to the PACU in good condition with no apparent complications.
-  
-SPECIMEN: Left middle phalanx material, preliminary pathology consistent with cartilaginous material. 
  
 +</WRAP>
  
 +<WRAP half column>
 +
 +Photos\\
 +{{:resident:screen_shot_2021-08-02_at_4.23.58_pm.png?600|}}
 +
 +Tourniquet: Forearm tourniquet\\
 +Drain: none\\
 +Sutures: 5-0 Nylon\\
 +Dressing: xeroform, 4x4 gauze, well padded radial gutter plaster splint\\
 +
 +Anatomy:
 +Enchondroma most commonly arises in the proximal phalanx or metacarpal when seen in the hand. It can be seen in metaphyseal and epiphyseal regions and is typically confined to the bone. The enchondroma may distend the bone and pathologic fracture may be seen.\\
 +
 +Post-operative care: Bulky protective dressings are applied and range of motion is initiated at the first dressing change, usually 8 to 10 days postoperatively.\\
 +\\
 +Periodic surveillance continues for 3 to 5 years.\\
 +\\
 +
 +Learning points/Pimp Questions:\\
 +\\
 +Make the bone window to the lesion two-thirds the greatest dimension of the lesion to allow adequate visualization of the cavity.\\
 +\\
 +Phalanx enchondromas can just have a bulky dressing, but metacarpal fractures usually require splinting for 6 weeks.\\
 +\\
 +These lesions are similar to giant cell tumors. Remember that these can recur late and metastasize.\\
 +{{:resident:screen_shot_2021-02-02_at_10.54.28_pm.png|}}
 +
 +
 +</WRAP>
 +</WRAP>
 ===== Plastics ===== ===== Plastics =====
  
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 Photos\\ Photos\\
 +{{:resident:screen_shot_2021-08-02_at_4.06.02_pm.png?600|}}
  
-Tourniquet: finger / forearm / arm\\+Tourniquet: none\\
 Drain: 15Fr drain\\ Drain: 15Fr drain\\
-Sutures: 3-0 PDS, 3-0/4-0 monocryl\\+Sutures: TE Tabs with 3-0 PDS, Skin with 3-0/4-0 monocryl\\
 Dressing: Doesn't like exophin d/t reactions. Steri, telfa, tegaderm\\ Dressing: Doesn't like exophin d/t reactions. Steri, telfa, tegaderm\\
  
-Anatomy: Pertinent anatomy should be listed\\ +Anatomy: \\ 
- +Breast Blood Supply: 
-Post-Operative Plan: +  - Perforating branches of internal mammary artery  Lateral thoracic artery 
 +  - Thoracodorsal artery 
 +  - Intercostal perforators 
 +  - Thoracoacromial artery 
 +  - Venous drainage mirrors arterial supply and predominantly to the axilla 
 +\\ 
 +Know the "Breast footprint" vs anatomical borders for surgical resection.\\ 
 +\\ 
 +The pectoralis major muscle has sternocostal, costal, and abdominal origins and inserts on to the proximal humerus. It is a type V muscle, with a dominant arterial pedicle from the thoracoacromial trunk and multiple secondary arterial sources from parasternal perforators.\\ 
 +\\ 
 +Post-Operative Plan: \\
 Can dc home or stay the night; admit to breast team\\ Can dc home or stay the night; admit to breast team\\
 Ancef x3 doses while in house, keflex on discharge for 10 days or until drains removed.\\ Ancef x3 doses while in house, keflex on discharge for 10 days or until drains removed.\\
 Continuous wearing of Compression Bra except while showering\\ Continuous wearing of Compression Bra except while showering\\
 +\\
 Learning points/Pimp Questions:\\ Learning points/Pimp Questions:\\
 +
 +  * The NAC is innervated by the anterolateral branch of the fourth intercostal nerve.
 +  * Supernumerary nipples and breasts can occur anywhere along the milk line from the axilla to the groin.
 +  * Attenuation of Cooper’s ligaments leads to ptosis and increased breast mobility.
 +  * The IMF is an important structure to preserve. Violation can be difficult to correct.
 +  * Injury to the intercostobrachial nerve results in paresthesias or anesthesia of the upper medial arm.
 +  * Perfect symmetry is rare.
 +  * Medial cleavage is difficult to create if it does not exist in the native breast.
 +
 +
 +
  
 </WRAP> </WRAP>
Line 1011: Line 1214:
 </WRAP> </WRAP>
 </WRAP> </WRAP>
 +
 +
 +==== Mangled Hand ====
 +
 +<WRAP group>
 +<WRAP half column>
 +
 +PREOPERATIVE DIAGNOSES:\\
 +1. Right mangled hand, crush injury
 +\\
 +
 +POSTOPERATIVE DIAGNOSES:\\
 +1. Right mangled hand, crush injury involving: index finger, long finger, ring finger, small finger, palm, dorsum of hand
 +2. Zone 2 crush injury, multilevel degloving, avulsion, extensive soft tissue damage, dorsal and volar to index finger, long finger, ring finger, small finger, palm, dorsum of hand (Zone VI), with near complete amputation of index finger, long finger, ring finger, small finger
 +\\
 +
 +Operative Report:\\
 +PROCEDURES PERFORMED:\\
 +1. Evaluation of right mangled hand, crush injury under anesthesia
 +2. Revision amputation of the right index finger at the level of the mid-proximal phalanx, with radial-based V-Y closure
 +3. Revision amputation of the right long finger at the level of the mid-proximal phalanx, with radial-based V-Y closure
 +4. Revision amputation of the right ring finger at the level of proximal phalanx, with ulnar-based V-Y closure
 +5. Revision amputation of the small finger just distal to the MCP joint (base of proximal phalanx preserved), with ulnar-based V-Y closure\\
 +\\
 +
 +The patient was transported to Operating Room #10 and placed supine on the table with pressure points appropriately padded. A pre-anesthesia time-out was performed. The patient was administered anesthesia without complication. Pre-operative antibiotic prophylaxis was administered - Ancef (tetanus status was verified in the ER). The surgical field was prepped and draped in the usual sterile fashion. A final time-out was performed. Anti-embolic compression devices were placed on bilateral lower extremities prior to induction. A Foley catheter was placed and removed at the end of the case.
 + 
 +A sterile upper extremity tourniquet was placed and the fingers were gently wrapped and the right upper extremity was elevated and exsanguinated with an Esmarch, and the tourniquet was inflated to 250 mmHg.
 + 
 +We began the procedure by evaluating the full extent of her injuries and the viability of the tissues. 
 +
 +RIGHT HAND:
 +INDEX FINGER: The index finger was found to have a near complete, circumferential degloving of the finger tissue in Zone 2, with a small radial-based soft tissue bridge. The flexor tendons were intact, however, there was injury to the central slip, the extensor tendon, and radial and ulnar neurovascular bundles. There was multi-level crush injury, most severe distally, with displaced, open fracture of P1. Due to the extent of the crush injury, at multiple levels, with poor viability of the soft tissue, and open fracture, it was determined that this would benefit from a revision amputation, with attempt to salvage as much of the surrounding soft tissue, as possible. The neurovascular bundle on the radial side of the digit was therefore carefully preserved, with dissection through Cleland's and Grayson's ligaments and used to create a radial-based soft tissue flap for coverage of the amputation site. The periosteum was cleared to the level of proposed amputation, at the mid-proximal phalanx, taking care to preserve the remainder of the surrounding soft tissue and periosteum. The neurovascular bundles were isolated proximally, the nerves were ligated with crush and Bipolar cautery and allowed to retract, and the vessels were ligated with bipolar cautery. The bone was then transected with a reciprocating saw, filed down with a rasp until smooth, and the wound was closed with the radial-based soft tissue flap with 4-0 simple interrupted Nylon sutures.\\
 +
 +(Each finger was evaluated/procedure described, as above)\\
 +
 +All amputated digits and debrided tissue was sent to pathology, as specimen. The palm was also found to have vertical lacerations extending into Zone 3, with exposed, but intact A1 pulley over the long and ring fingers. The A2 pulley was avulsed on the long, ring, and small fingers. The dorsum of the hand also had puncture wounds over Zone VI, which was inspected and were irrigated thoroughly. A total of 9L of NS was used to irrigate the wounds prior to closure. There were no foreign bodies noted.\\ 
 +
 +The patient had a postoperative supraclavicular block by the anesthesiology team. Please see separate documentation for additional details.\\
 +The patient was awoken from anesthesia and transferred to the PACU in good condition with no apparent complications.\\
 +
 +</WRAP>
 +
 +<WRAP half column>
 +
 +Photos:\\
 +
 +{{:resident:4b81ee93-a538-4d73-bcdd-69a7f7676f47.jpeg?400|}}
 +{{:resident:6ee38d74-ded0-442b-9d3d-e291b915236c.jpeg?400|}}
 +{{:resident:38f5db49-24b7-4ad6-bb5c-a97a2bc796da.jpeg?400|}}
 +{{:resident:80cb6adc-ba8a-44a4-a6a9-1714c1b519da.jpeg?400|}}
 +{{:resident:93b3cbfc-8cfc-487b-94d1-de3a6be9073f.jpeg?400|}}
 +{{:resident:321b5b0e-52a1-455c-87f1-524467fa4591.jpeg?400|}}
 +{{:resident:d04fca21-4ab8-4f25-ad14-7c6a999f56d9.jpeg?400|}}
 +{{:resident:e580c06a-109d-4d2f-8eb0-69d988c0e945.jpeg?400|}}
 +{{:resident:5824e227-8a11-4c27-9a54-c326aa016e0a.jpeg?400|}}
 +{{:resident:ab12daaf-2171-4544-9196-6f1552e06f49.jpeg?400|}}
 +{{:resident:e7ad6d9e-0024-4fb6-a46f-50628a4ea198.jpeg?400|}}
 +{{:resident:ee4de1aa-f0c6-4bbd-87b3-790027a514c9.jpeg?400|}}
 +\\
 +
 +Tourniquet: Forearm / arm\\
 +Drain: None\\
 +Sutures: 4-0 Nylon simple interrupted\\
 +Dressing: Adaptic with bacitracin ointment over all suture lines, 4x4 gauze, Webril, bulky Jones, bias\\
 +
 +Anatomy: Flexor/extensor zones of injury\\
 +
 +Post-operative care: Gentle graduated compression with the bulky Jones/bias placement. Maintain dressings until postoperative appointment in clinic. There is an orthopedic psychology team at Denver Health that specifically cares for patients that are at high risk for PTSD after injury/amputees. Consult should be placed while inpatient and the patient should be seen prior to discharge.\\
 +
 +Attending Pearls (Learning points/Pimp Questions): Assess viability of tissue and then assess structure-by-structure or spare parts. Bony fixation/amputation first, then tendons, neurovascular structures, then soft tissue closure.\\
 +
 +</WRAP>
 +</WRAP>
 +
resident/stephanie_malliaris.1612331364.txt.gz · Last modified: 2021/02/03 00:49 by jonathan
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